Vsim Carla Hernandez Pre/Post-test | Questions and Answers(A+ Solution guide)

A woman in active labor reports to the nurse that she thinks that her bag of waters has broken. What is the first assessment that the nurse performs at this time? - Monitor the fetal heart rate and pattern Explanation: When the fetal membranes rupture, then the presenting part can put pressure on the umbilical cord. the first assessment to make is the fetal heart rate and pattern to ensure the fetus is getting enough oxygen through the umbilical cord The labor and delivery nurse notices that a laboring woman's external fetal monitor shows a variable deceleration. what is the common etiology of this non-reassuring fetal periodic pattern? - Cord compression Explanation: Fetal variable decelerations are commonly associated with umbilical cord ompression Which of the following statements is true concerning prolapsed umbilical cord? - It is an emergency that requireds immediate measures to minimize the fetal mortality or mobidity from hypoxia Explanation: The occurence of the prolapsed umbilical cord is approximately 1 in 300-600 births, or 3% of the cephalic presentations and 3.7% of breech presentations. A prolapsed umbilibal cord is an obstetric emergency that requires immediate attention to prevent acidosis from the fetal hypoxia. he nurse is admistting a labor woman at 39 weeks gestation. Which of the following are risk factors for prolapsed umbilical cord (sata) - Estimated fetal weight of 2,400 g (5 lb, 1 oz) Amniotomy performed at station -2 Multiple gestation Amniotic fluid 2,200 mL Explanation: risk factors for an umbilical cord prolapse incude the following" Low birth weight, being second twins, transverse lie, breech presentation, preterm labor (less than 37 weeks), Poly hydramnios (greater than 2,000 mL), amniotomy (especially when fetus is not engaged), prematuer rupture of the membranes, placenta previa, and a long cordWhich of the following nursing measures has the highest priority when an intrapartum woman has a prolapsed umbilical cord? - Place sterile gloved hand into patient's vagina to push the fetus off the umbilical cord Explanation: The immediate concern is to reestablish blood flow through the umbilical cord. Whu, the nurse woulf push the presenting part off the cord to relieve the compression. Position changes to relieve cpmpression: knee-to-chest, trendelenburg, hips higher than chest, modified Sims The nurse takes measures to preserve the integrity of the visible umbilical cord prolapse to maintain blood flow to the fetus. Which of the following are appropriate measures? (sata) - Assess the exposed umbilical cord for color and pulsation Use a gloced hand to lift the presenting part of the cord Explanation: The nurse would try to reestablish blood flow to the fetus by placing a gloved hand into the vagina and lifting the presenting part off the cord. the exposed umbilical cord is not pushed back into the vagina, because this action could cause the umbilical vessels to be kinked and cut off the blood flow to the fetus What is the primary purpose for a provider order for terbutaline sulfate to be given to a laboring patient who presents with a prolapsed umbilical cord? - To relax the uterine smooth muscles to allow for impoved fetal blood flow